09HDC01565 - Health and Disability Commissioner

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Health and Disability Commissioner overnight; a conflict between the postoperative instructions for Mr A and the SCU protocol; and the practice of conducting morning handover for SCU patients in another room. Accordingly, CDHB did not take reasonable actions in the circumstances to ensure that services were provided to Mr A with reasonable care and skill, and breached Right 4(1) of the Code of Health and Disability Consumers‘ Services Rights (the Code). 3 8. Mr A was not informed as to who would be performing his surgery. This is information that a reasonable consumer, in these particular circumstances, would expect to be given. In addition, there were some deficiencies in the nursing care provided by RNs Ms I, Ms J and Ms K. However, in the circumstances it was found that individual breach findings were not warranted. Investigation process 9. On 10 August 2009, the Commissioner received a complaint from Mrs C about the services provided to her son, Mr A. An investigation was commenced on 3 November 2009. The following issues were identified for investigation: Whether CDHB provided Mr A with an appropriate standard of care on Days 1-3. Whether Dr E provided Mr A with an appropriate standard of care from the time of Mr A’s diagnosis of Chiari malformation in 2008, to his death. Whether Dr E provided Mr A with an adequate explanation of his condition and with sufficient information to enable him to make an informed choice about the options available to treat his condition, including an assessment of the expected risks and benefits of surgery. Whether Dr F provided Mr A with an adequate explanation of his condition and with sufficient information to enable him to make an informed choice about the options available to treat his condition, including an assessment of the expected risks and benefits of surgery. 10. On 1 April 2010, the scope of the investigation was extended to include the following issues: Whether registered nurse Ms I provided Mr A with an appropriate standard of care on Day 2. Whether registered nurse Ms J provided Mr A with an appropriate standard of care on Days 2 and 3. Whether registered nurse Ms K provided Mr A with an appropriate standard of care on Day 3. 11. The scope of the investigation was further extended on 12 April 2011 to include the following issue: 3 Right 4(1) — Every consumer has the right to have services provided with reasonable care and skill. 5 September 2012 2 Names have been removed (except Canterbury DHB and the experts who advised on this case) to protect privacy. Identifying letters are assigned in alphabetical order and bear no relationship to the person’s actual name.
Opinion 09HDC01565 Whether Dr F provided Mr A with an appropriate standard of care on Days 1-3. 12. The parties directly involved in the investigation were: Mr A (dec) Ms B Mrs C Mr C Dr D Dr E Dr F Dr G Dr H Ms I Ms J Ms K Consumer Consumer‘s fiancée Complainant/Consumer‘s mother Consumer‘s father General practitioner Consultant neurosurgeon Neurosurgical trainee/registrar Neurosurgical trainee/registrar Anaesthetist Registered nurse Registered nurse Registered nurse Also mentioned in this report: Ms L Ms M Ms N Dr O Mr P Registered nurse Registered nurse Registered nurse On-call registrar Ms I and Ms K‘s legal representative 13. Information was reviewed from: Mr and Mrs C, Dr D, CDHB, and CDHB staff including Dr E, Dr F, Dr G, RN Ms I, RN Ms J, and RN Ms K. 4 14. Independent expert advice was obtained from neurosurgeon Dr Darryl Nye (Appendix 1) and RN Janet Hewson (Appendix 2). Information gathered during investigation Diagnosis and pre-admission 15. In 2008, Mr A (aged 21 years) consulted a general practitioner, Dr D. Mr A was fit and active, but had been having frequent headaches, brought on by activity that increased his heart rate. Dr D conducted a full medical the following day, and recommended he restrict physical activity. Dr D discussed Mr A with a neurologist at the public hospital, and prescribed medication to slow his heart rate (nadalol). 16. In 2008, Mr A had an MRI of the brain, which showed: ―Significant cerebellar descent consistent with a Chiari one anomaly‖. Dr D referred Mr A privately to 4 Mr A‘s fiancée was invited to contribute but declined to do so. 3 5 September 2012 Names have been removed (except Canterbury DHB and the experts who advised on this case) to protect privacy. Identifying letters are assigned in alphabetical order and bear no relationship to the person’s actual name.
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09HDC01565 - Health and Disability Commissioner

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